Violence, condom negotiation, and HIV/STI risk among sex workers.

IN MOST PARTS OF THE WORLD, SOME OR ALL ASPECTS OF sex work are criminalized. Consequently, sex workers have few legal protections and may easily be exploited or abused by clients, coworkers, and law enforcement officials. The isolation and disempowerment of sex workers, enforced by the threat of violence, may create barriers to negotiating safe sex practices, thereby increasing the risk for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Violence against sex workers by exploitive clients, police, or managers (including pimps) is enabled by a lack of legal protection for sex workers’ rights in areas where sex work is criminalized. Understanding the link between violence against sex workers and condom use can be a key to understanding why some sex worker populations are particularly vulnerable to elevated rates of HIV/STI infection compared with the general population, a reality documented in both concentrated and generalized HIV epidemics. Violence against sex workers is related to cultural and religious taboos associated with female sexuality and the sale of sex. Throughout the world, these cultural taboos have become institutionalized by defining sex work as criminal behavior, with enforcement of sanctions directed more often against sex workers than their clients. Violence against sex workers is mediated by social, legal, law enforcement, and workplace factors, which vary across and within regions. For example, in North America, Central and Eastern Europe, and Central Asia, criminal laws prohibit communicating (ie, solicitation) for prostitution in public spaces and operating brothels. Criminalization of this kind gives police broad latitude to arrest and threaten arrest of sex workers, which may cause street-based sex workers to move from town centers to more isolated spaces such as rural highways or industrial settings where arrest is less likely or there is some level of informal tolerance of sex work. The isolation of these settings, however, can enable violence with impunity as witnesses and places to flee violence are few. For sex workers who work in brothels or other indoor establishments, clients often negotiate the sexual services and fees directly with the management, and sex workers receive an hourly rate with little to no control over selection of clients or negotiation of types of services. This lack of control may also increase the risk of episodes of violence. Where sex work is criminalized, sex workers may have to pay a fee or bribe to police or managers for some measure of protection from violence or arrest. Population-based data on incidence of violence against sex workers remain scarce. Two studies of countries in Central and South Asia and Europe and North America have estimated a prevalence of physical and sexual violence of between 40% and 70% among sex workers over a 1-year period. Particularly where sex work is criminalized and police are not motivated to protect sex workers, violence and threats of violence can be ubiquitous in the daily life of a sex worker and may include verbal harassment and abuse, physical assault, forced confinement, violence with a weapon, and rape. In addition to violence by exploitive clients, police, and managers, perpetrators of violence against sex workers can also include partners, illicit drug dealers, and exploitative business owners. Violence or the threat of violence may be used to coerce unprotected, unpaid, or risky sexual services (eg, anal sex); or to extort money or fees by exploitative managers or sex business owners. Incidents of violence by police are reportedly common in some settings, including excessive use of force, harassment, unlawful and invasive body searches, fines and detainment without arrest or formal charges, beatings, rape, and coerced sex for bribes. In a 2009 survey of sex workers in Central and Eastern Europe and Central Asia, 42% reported physical abuse by police, and 37% reported having been assaulted sexually by police, with the highest rates in Macedonia, Ukraine, and Kyrgyzstan. Although the link between intimate partner violence and condom negotiation has been well established in the general population, data on violence and condom negotiation in sex work has only begun to emerge. These data suggest that when violence against sex workers is pervasive and largely unaddressed, sex workers are forced to prioritize the